Health inspection·February 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the Care Plan to ensure a fall did not occur for one (R1) resident of three residents reviewed for falls/accidents in a sample of three Findings include: The facility's Incidents and Accidents Policy, dated 12/6/22, documents: It is the policy of this facility for staff to utilize (Electronic Health Record)/Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. R1's diagnoses included: Dementia, psychotic disturbance, mood disturbance, chronic kidney disease, malignant neoplasm of bladder, chronic obstructive pulmonary disease, retention of urine, urinary tract infection, cerebrovascular disease, weakness, other abnormalities of gait and mobility, history of falling, acute kidney failure. R1's Care Plan documents: The resident has an Activities of Daily Living/ADL self-care performance deficit related to weakness. The resident has limited physical mobility related to muscle weakness, dementia. The resident has impaired cognitive function/dementia or impaired thought processes related to dementia diagnosis. R1's Fall Risk assessment dated [DATE], documents: (R1) is at high risk for falling; (R1) overestimates or forgets limits. R1's Progress Note Dated 1/20/24 documents: Ground level fall at 200 hall nursing station, resident ambulating unassisted and fell, struck right side of head with laceration noted. Resident made comfortable and will let Emergency Medical Transport/EMTs lift resident up due to head injury. R1's Report to (State) Department of Public Health, Incident Date 1/20/24, documents: R1 Attempted to self-ambulate which resulted in fall, sent to Emergency Room/ER for evaluation. Investigation initiated. Type of Injuries: Six centimeter laceration to right forehead closed with five staples. R1's Hospital Notes, dated 1/22/24 documents: Assessment: Acute nondisplaced fracture involving the right posterior lamina; acute nondisplaced fractures involving the temporal process of the right Page 1 of 2 145600 145600 02/13/2024 Loft Rehab & Nursing of Canton 2081 North Main Street Canton, IL 61520

F 0689 zygomatic bone and the right greater wing of the sphenoid. Plan: No surgery needed to facial fractures. Level of Harm - Minimal harm or potential for actual harm R1's Minimum Data Set (MDS), dated [DATE], documents: R1 has a BIMS (Brief Interview of Mental Status) score of 12. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) Residents Affected - Few On 2/13/24 at 10:45am, V3 Assistant Director of Nursing/ADON) stated when R1 was admitted to the facility on [DATE], he resided on the facility's 100 Hall close to the nursing station; and stated that R1 was initially rehab to home but became long term and was transferred to the 200 Hall. At this time, V3 ADON stated, The 200 Hall has two Certified Nursing Assistants/CNAs; most of the residents with dementia would go to the 200 hall; (R1) had dementia. Someone should have had eyes on him at all times because he is high risk for falls. On 2/8/24 at 1:35pm, V8 Licensed Practical Nurse/LPN stated that she was R1's nurse when he fell on 1/20/24; stated that at the time of his fall, she was doing Accu-checks and the two staff Certified Nursing Assistants/CNAs (V9 and V13) assigned to the 200 Hall were passing meal trays to the room residents. On 2/8/24 at 1:35pm, V8 LPN stated, Most of the residents were in the dining area across from the nursing station and I would be able to keep an eye on them. (R1) was at the back door near the nursing station, sitting in his wheelchair and looking out; I went to do another Accu-check and heard a resident say, 'that man just fell'. (R1) tried to ambulate unassisted; has a history of falls, no safety awareness. We like to keep an eye on him; the fall happened so quickly. I felt terrible. At this time, V8 LPN stated that R1 had lots of blood coming from his head; stated that she notified the EMT/Emergency Medical Transport right away. V8 LPN stated, (R1) did not come back to the facility; was transferred to a (local hospital) for head injury and brain bleed, then went to hospice. On 2/9/24 at 12:25pm, V9 Certified Nursing Assistant/CNA stated she worked on the 200 Hall where R1 resided and was his CNA when he fell; stated that when she saw him on the floor, he was not saying anything. At this time, V9 CNA stated, (V13 CNA) and I were passing the lunch trays at the other end of the hall; it takes both of us; and V8 LPN was watching the residents in the dining room. If V8 LPN was not watching them, either me or (V13 CNA) would have been watching. On 2/9/24 at 12:30am, V13 CNA stated when R1 fell, R1 was face down on the floor and breathing funny; bloody from head; did not respond to them when they talked to him. At this same time, V13 stated, The nurse (V8 LPN) was watching (R1); think he popped up and tried to walk; he is fast. There were a room full of residents down there (dining area/nursing station); he was not by himself. Someone has to watch residents at all times, and the nurse (V8 LPN) was there. 145600 Page 2 of 2